Top Priority for Surprise Billing Implementation: Protecting Patients from Higher Health Care Costs

In a new letter to the Biden Administration, members of the Coalition Against Surprise Medical Billing made it clear that achieving the intended goals of the No Surprises Act would require a firm commitment to “decrease health care costs, including premiums and patient cost-sharing” caused by out-of-network providers and private equity firms continually exploiting their market power at the expense of consumers.

The letter comes ahead of an anticipated first regulatory milestone in the implementation of the No Surprises Act. Coalition members, as well as leading consumer, union and employer partners, have repeatedly urged the Biden Administration to adhere to the legislative intent and language of the No Surprises Act which makes clear that the qualifying payment amount (QPA), on which patient cost-sharing is based, should be the primary factor in resolving payment disputes. Highlights from the letter are included below:

• “As the Biden Administration moves forward with implementation of the No Surprises Act, we are providing additional recommendations on several key provisions of the law and upcoming regulatory guidance that are critical to achieving the comprehensive patient protections and cost containment intended by Congress.”
• “The No Surprises Act was intended to reduce overall health care costs by correcting a longstanding market failure. Achieving this goal will require that independent dispute resolution (IDR) is used as a limited, last resort for disputes that cannot be negotiated, rather than an avenue for inflating costs once the patient is taken out of the middle.”
• “To achieve the cost-savings projected by the Congressional Budget Office (CBO), regulations should ensure the qualifying payment amount (QPA) is the presumptive consideration in IDR determinations. This is consistent with the statute and Congressional intent, as well as the CBO score.”
• “Third-party databases that rely on billed charges and inflationary (or above market) allowed amounts should be explicitly prohibited as a basis or shortcut for deriving the QPA. As we understand, currently many third-party databases, including FAIR Health, reflect or include providers’ billed charges – the invented list price unilaterally set by the provider and separate from any negotiated, in-network contract determined by the health plan or the provider.”

To view the full letter, including recommendations on key patient protections related to notice and consent provisions, click here.